february 28, 2015 - acp · 1:15‐1:40 arthrocentesis and steroid injections of the knee and...
TRANSCRIPT
Joint Injection WorkshopACP Scientific Meeting
February 28, 2015
Andrea M. Barker, MPAS, PA‐CMichael J. Battistone, MD
Workshop Schedule1:00‐1:15 A Practical Approach to the Shoulder Exam
1:15‐1:40 Arthrocentesis and Steroid Injections of the Knee and Shoulder
1:40‐1:45 Transition
1:45‐2:05 Hands‐on Session I*Shoulder ExamsKnee Injections
2:05‐2:25 Hands‐on Session II*Shoulder ExamsKnee Injections
* Joint Injection simulators are available during this time
Examination Performed Technique Adequate
FROM BEHIND 1 Observation Adequate exposure Observe as they disrobe for
degree of discomfort General Symmetry, scars, skin lesions,
erythema, edema, atrophy Scapular winging Patient raises arms bilaterally
Wall press 2 Palpation Bilateral Sternoclavicular joint Acromioclavicular joint Biceps tendon Lateral shoulder Inferior to acromion FACING PATIENT
3 4
Range of Motion Motor Function of Rotator Cuff
Bilateral
Supr
aspin
atus ROM: Active forward elevation in scapular plane
Painful arc (>90’) Drop arm test
Scapular plane Neutral rotation (thumbs to ceiling)
Motor: Empty Can Test
Scapular plane Full pronation (thumbs to floor) Resisted forward elevation
Infra
spina
tus ROM: Active external rotation Elbows at side
Motor: Active external rotation against resistance
Elbows at side Start with hands near midline
Unilateral
Subs
capu
laris
Motor: Belly Press Test
Hand on abdomen Elbow anterior to midline Examiner pulls at forearm Watch for elbow to drop
ROM: Active internal rotation along spine Observe patient from behind Motor: Lift Off Test
Hand at lumbar spine Actively lifts off back against resistance
Tere
s Mino
r
ROM: Active external rotation with 90’ shoulder abduction and 90’ elbow flexion
90' shoulder abduction 90' elbow flexion Thumb points posterior
Motor: Hornblower’s Test External rotation as above against
resistance Note: check passive range of motion if active is limited.
This will identify mechanical block of motion versus shoulder weakness
Anatomy
5 Components of Shoulder Exam1. Observation2. Palpation3. Range of Motion4. Motor Function of the Rotator Cuff5. Provocative Testing
ADEQUATE EXPOSURE!!!
1. Observation• Symmetry• Skin lesions/scars• Erythema• Scapular winging• Atrophy
2. Palpation• Bilateral palpation from behind patient
SC joint AC joint Biceps tendon
(long head) Subacromial space
(lateral and posterolateral)
Note locations of tenderness to help guide examination
4. Motor Function of Rotator Cuff• Monitor each maneuver for pain as well as strength
• Pain but normal strength: tendonitis or partial‐thickness tear
• Pain with weakness: concern for full‐thickness tear• Compare strength with unaffected side
• Start with active ROM and perform passive ROM if active is limited
Supraspinatus
ROM: Active forward elevation in scapular plane• Bilateral• Elbows extended• Thumbs to ceiling
• Painful Arc (pain >900 ABD)• Drop Arm Test
Abduction Forward elevation
Supraspinatus
Motor: Empty Can Test• Bilateral• Internal rotation (thumbs
toward floor)• Elbows extended• Downward pressure by
examiner• 90˚ or lower
Abduction Forward elevation
Infraspinatus ROM: External rotation
• Bilateral• Elbows at side, 90 degrees of flexion
• Examine for symmetry
Infraspinatus
Motor: external rotation test– Bilateral– Elbows at side, 90 degrees of flexion
– Hands near midline– Examiner resists ER
External rotation
Subscapularis
Motor: Belly Press Test• Unilateral• Elbow anterior to midline• Examiner attempts pull arm off abdomen at the wrist
Internal rotation
Subscapularis
ROM: Internal rotation along spine• Unilateral• Repeat on unaffected side for comparison
Internal rotation
Subscapularis
Motor: Lift‐off Test• Unilateral• Dorsum of hand
against lumbar spine• Patient attempts to lift
hand off back against resistance
• Resistance applied at wrist
Internal rotation
Teres Minor
ROM: External rotation in abduction• Unilateral• 90 degrees shoulder abduction• 90 degrees elbow flexion• Thumb toward ceiling• Patient attempts ER
“hitchhiking”
External rotation
Teres Minor
Motor: Hornblower’s Test• Unilateral• 90 degrees shoulder
abduction• 90 degrees elbow flexion• End position of ROM test• Examiner resists ER
External rotation
5 Provocative Testing Impingement Testing Hawkin’s Test Shoulder 90' abduction
Scapular plane 90' elbow flexion Internal rotation + horizontal adduction
Neer’s Test Elbow extended Full pronation Maximal passive forward elevation of shoulder with scapular stabilization
Biceps Testing Speed’s Test 60' forward elevation
Hand in supination 20-30' elbow flexion Apply downward pressure to forearm
Yergeson’s Test Elbow at side, 90' flexion Palm in supination Resisted supination
AC Joint Testing
Cross-arm Test Active horizontal adduction
Subacromial Impingement• Area between humeral head
and acromion• Narrowed space
– Bony changes• Acromion type• AC spurs• Cuff arthropathy
– Soft tissue swelling• Bursa• Rotator cuff
Subacromial Impingement Testing• Hawkin’s Test
– Passive– 90˚ abduction, 90˚ elbow
flexion– Scapular plane– Maximal internal rotation
• Neer’s Test– Passive – Elbow extended– Pronation– Sagittal plane– “Near to the ear”
Biceps Tendinopathy Testing• Speed’s Test
– 60˚ forward elevation– 20‐30˚ elbow flexion– Downward pressure at forearm
• Yergason’s Test– Elbow at side, 90˚ flexion– Palm in supination– Examiner attempts to pronate
Acromioclavicular Joint Testing
• Cross‐arm Test– 90˚ forward elevation– Maximal horizontal adduction
Pain must be localized to AC joint for test to be positive
Neurologic Testing• Spurling’s Test
– Slight neck extension– Rotation toward affected shoulder
– Axial loadNeurologic Testing Motor Shoulder abduction, forearm supination (C5) Elbow flexion, wrist extension (C6) Elbow extension/wrist flexion/finger extension (C7) Finger flexion/thumb abduction (C8) Reflexes Biceps (C5, C6) Brachioradialis (C6) Triceps (C7, C8) Sensation Deltoid (C5) Radial aspect of arm/hand, thumb (C6) 3rd digit (C7) Ulnar aspect of arm/hand and 5th digit (C8)
Arthrocentesis and Corticosteroid Injections of the
Knee and Shoulder
Am I Ready? • Do I have a good indication? • Do the risks outweigh the benefits? • What size needle and syringe will I use? • What medications do I want to use? • Will I anesthetize the skin? • Which approach is most reliable and least painful?• What will be considered a successful outcome? • What can I tell the patient to expect during & after?
Overview• Contraindications/risks to corticosteroid (CS) injections• Preparation prior to procedure• Intra‐articular (IA) knee injection
– Indications– Approach– Patient positioning + procedure
• Subacromial (SA) injection of the shoulder– Indications– Approach– Patient positioning + procedure
Contraindications/Cautions• Prosthetic joint• Recent surgical procedure involving the joint• Joint surgery anticipated in the next 3 months• Overlying cellulitis• Supratherapeutic anticoagulation• Medication allergies• Suboptimal response to prior injection• If concern for septic arthritis, contact orthopedics or rheumatology
Do Risks Outweigh Benefits? • Significant Risks and Complications
– Infection1– Post‐injection flare– Bleeding– Increase in blood glucose– Lack of response/no improvement2
• Things to Consider– Tendon rupture– Skin atrophy/hypopigmentation – Suppression of the hypothalamic‐pituitary axis
Pre‐Procedure Checklist
1. Informed consent
2. Documentation plan
3. Supplies prepared
Supplies
KEY: Be consistent with needle gauge and syringe sizeThis produces consistent resistance during injections; increased resistance
suggests injection of medications into soft tissue/tendon
21 Gauge 1.5 Inch Needle + 10cc Syringe
– Recommended for SA and IA injections– Fast delivery, can still feel resistance– Can be used for aspiration
18 gauge needle + 20‐30cc syringe Aspiration of large effusion or hemarthrosis
Medications
Use single‐dose vials when possible3,4
Anesthetics: Lidocaine + Bupivacaine• Mix in syringe with CS
– Dilution and dispersion of steroid• Decrease risk post‐injection flare, local atrophy
• Fast‐onset with lidocaine (1‐2cc total)– Facilitates diagnosis
• Long duration with bupivacaine (1‐2cc total)– Bridges gap with onset of CS
Should I Anesthetize the Skin? • Local anesthetic not necessary or recommended
– More painful– Limits feedback on accuracy of needle placement
• Ethyl chloride spray not recommended
• KEY: Get needle through skin quickly and deliberately
Which Corticosteroid Should be Used? • No large RCTs comparing various preparations
• American College of Rheumatology Survey5
– Triamcinolone acetonide (Kenalog) in the West– Methylprednisolone (Depo‐Medrol) in the East
• Both agents comparable for SA shoulder injection6
• Both may have less chance of post‐injection flare
Body Area Specific LocationCorticosteroid Dosing Recommendation
(Methylprednisolone equivalent)
Shoulder Subacromial 40mg
Glenohumeral joint 40‐80mg
Acromioclavicular joint 20mg
Knee Intra‐articular 40‐80mg
Pre‐patellar bursa 20‐40mg
Pes anserine bursa 20mg
Hip Greater trochanteric bursa/area 20‐40mg
General rule for methylprednisolone equivalent: ‐ 120mg in 1 day‐ 160mg in 4 weeks
Process of Drawing up Medication
• Open 10cc syringe and attach 18 gauge needle
• Open medication vials and wipe tops with
chlorhexidine
• Draw medication into syringe; start with multi‐dose
• Cap 18 gauge needle but don’t remove from syringe
• Open gauze and bandage, set near patient
Ready For Procedure…Pre‐procedure checklistiMed ConsentOut of OR Time Out NoteSupplies prepared and near patient
Marking injection siteSterile prep
“No‐touch” technique
Marking the Site• Retractable pen
Sterile Prep
• Chlorhexidine over iodine7
• Must be mechanical scrub• 2 swabs, 30 seconds each• Silver dollar area
“No‐Touch”Technique
• Use final prep to confirm location &hand placement
• Non‐sterile gloves• Indentation remains
Intra‐articular Knee InjectionIndicationsApproach
Patient PositioningProcedure Checklist
Do I Have a Good Indication for a Knee Aspiration and/or Injection?
• OA– ACR conditionally recommends8– AAOS inconclusive9
• Degenerative meniscus tear• Known inflammatory disease with exacerbation• Question of inflammatory disease – needing confirmation of crystals
• Avoid in younger patients/those with normal cartilage
Approach to Knee Injection
Flexed Knee• Anteromedial joint line• Anterolateral joint line
Extended Knee• Lateral midpatellar• Superolateral patellar
Accuracy Review10‐12
Flexed Knee
• Anterolateral joint line– 67‐71%
• Anteromedial joint line– 72‐75%
Extended Knee
• Lateral midpatellar– 85‐93%
• Superolateral patellar– 87‐91%
• Improved accuracy • Effusion present• Provider experience
• Recommend when starting out to pick one technique and use the same approach every time
Sagittal Knee`
Axial Knee
Recommendations• 1st choice
Superolateral patellar or lateral midpatellar– Improved accuracy– Potentially less painful
• AlternateAnterolateral or anteromedial joint line– When body habitus limits landmarks in extension– Severe PF OA with large lateral patellar osteophytes
Patient Positioning
• Supine• Bridge from pelvis to ankle • Maximal tolerated hyperextension*• Point toes and patella to ceiling• Keep quadriceps relaxed (may require additional person to stabilize the foot)
• Elevate patient to place entry site at eye level
Procedure 1. Identify the upper 1/3 of patella2. Displace and tilt lateral edge of patella3. Find entry point: soft indentation just
posterior to lateral patellar edge 4. Needle entry:
1. Perpendicular to femur2. Parallel to ground
1. Identify the upper 1/3 of patella
2. Displace patella lateral and tilt lateral edge up3. ID entry point: soft indentation just posterior to lateral patellar edge 4. Needle entry: Perpendicular to femur + parallel to ground
Procedure
5. Insert needle quickly through skin, then slowly advance through synovium(0.5 to 1 in)
Knee Injection Summary:Superolateral or lateral midpatellar approach
Positioning
• Maximal hyperextension• Toes to ceiling• Relax quads • Eye level
Procedure
• Upper 1/3 of patella• Displace and tilt • Perpendicular to femur• Parallel to ground
Subacromial Shoulder Injection
IndicationsApproach
Patient PositioningProcedure Checklist
Do I Have a Good Indication for Subacromial Injection of the Shoulder? • Impingement Syndrome/SA bursitis• Rotator cuff tendinitis/partial‐thickness tear
– Failed conservative management
• Inoperable full‐thickness rotator cuff tear• Rotator cuff arthropathy
– Get both SA and GH areas
• Not indicated for primary GH OA– No connection unless full‐thickness tear
Subacromial Injections
Approach
Posterior Lateral
Patient Positioning• Patient seated• Arm hanging at side, relaxed• Provider stands behind patient• Injection site at eye level
Procedure1. Identify anterior and
posterior acromion2. Note angle of acromion3. Find entry point:
– 1 cm inferior and medial to posterior corner
4. Needle entry:– Parallel to acromion angle– Saggital plane
5. Insert needle 1‐1.5 in.– Tip under mid to anterior
acromion
Troubleshooting• Always aspirate before injecting
• If resistance encountered:– First, rotate needle 180 degrees– Next, withdraw few millimeters– Finally, withdraw a few more millimeters and redirect slope of needle by 5‐10 degrees
Documentation Requirements• See handout
Synovial Fluid Analysis• Purple‐top tube
– Cell count and differential– Crystal analysis
• Original syringe with cap– Gram stain and culture
• Label each tube– Patient name– SSN– Date/time collected– Location (“Right knee”)– Order number
Summary Recommendations• 21 gauge 1.5 inch needle with 10cc syringe• Medications (can be used for both procedures):
– 1cc = 40mg methylprednisolone or equivalent– 2cc 0.1% lidocaine– 2cc 0.5% bupivicaine
• Do not anesthetize the skin• Prep skin with chlorhexidine• Use the “no‐touch” technique • Position patient with entry site at eye level• Use same approach for each procedure
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